Documentation Flashcards
Why are pt records imptnt for legal documentation?
Accountability
Best defence in court
Not written= not given
What are the purposes of documentation?
Communication& care planning Legal documentation Education Research Funding of resource management Quality review
What are the purposes of education around pt records?
Each pt is unique, teaches student about bhvr patterns and illness care
Why are pt records important for research?
Data for statistical purposes
Analysis of data for research processes
Why is documentation important doe funding and research management?
Shows what and how HC resources used
With pt acuity helps determine type and amount of resources required
Why is documentation important for quality review?
Evaluate care
Audit chart
Multidisciplinary team
Deficiencies shared which then practice and policy can be changed.
Guidelines for quality documentation?
Factual info Complete Accurate complies with standards Current Organized
What is documentation?
any written/electronical info abaout client describing care or service provided to pt
What is the purpose of documentation?
Communication and Care planning Legal Documentation education Funding of resource management Research Quality Review
Documentation allows for communication and care planning which?
HCT communicate pt needs, progress, care, tx, and education admission till discharge consistency and continuity of care reflects nrs process baseline data provider
How does documentation legally affect us?
demonstrates accountability for practice
best defense
care not given if not documented
need to document assessments, care, pt response, instructions and referrals
How is documentation good for education?
each pt is unique
begin to recognizze illness and its patterns of bhvrs
enables st to see patterns and types of care provided and needed
How does documentation related to funding and resource managment?
shows how HC resources have been used
Levels of acuity of pt determines resources needed
helpful for hrs of nrs care and qualifications of HC provider
What is documentation helpful for research?
Data for statistical purposes :rate of recovery/infection
analysis of data for research purposes
Why is doccumentation a good quality review?
eval of quiality and appropriateness of care
audit chart after discharge/while pt is hospitalized
multidisciplinary team
deficiencies are shared, change practice and policies
What are the guidelines for quality documentation?
Factual Accurate Complete Current Organized
What is factual info?
descriptive, objective data\
inferences only with supporting factual data
subjective data exact
avoid appears, seems, apparently
What are characteristics of accurate data?
accurate and specific time, amt, size, description and response acceptable abbrevs. symbols clear and concise intials after each time chart observations
What is complete and current documentation?
complete, appropriate thorough, pt condition, care given, and response
timely, chart flow sheets at bedside
data recorded at time of occurence
What is organized documentation?
logical order
What kind of documentation complies with standards?
pt name and id #, date of fata on each page time with every entry sig/ status of recorder chart only care given no blank spaces chronological order if not "late entry" no erasers/white out or pencils charting error no ditto marks legible
What does focus charting include?
current pt concern/bhvr
change in condition/bhvr
significant event in tx
key word from a nurs dx. flow sheet or complance with a standard of care
DARP or DARE (Data, action or future actions, Response, plan/expected outcome)
What is an audit?
review of pt record designed to identify, examine, or verify performance of certain specified aspects of nursing care
Problem orientated Med Record?
method of recording data about health status of pt in prob solving system
Narrative Charting?
most traditional, includes care given, observations, responses, chronological and paragraph format
What are disadvantages to the narrative format?
lengthy, little structure, scattered info, time consuming
